A postsurgical client has been receiving morphine by patient-controlled analgesia for 2 days. What action by the nurse best addresses potential adverse effects?
administering a stool softener as prescribed
auscultating the client's lung for adventitious sounds
encouraging active range of motion exercises
applying calf compressors as prescribed
The Correct Answer is A
A. Administering a stool softener is essential as opioids like morphine commonly cause constipation, and this proactive measure helps mitigate that adverse effect.
B. While auscultating the lungs is important to monitor respiratory function, it does not specifically address a common adverse effect of morphine.
C. Encouraging active range of motion exercises can help prevent complications from immobility but does not directly address the most common adverse effect of morphine.
D. Applying calf compressors can help prevent deep vein thrombosis, but it is not the most effective action for addressing the specific adverse effects of morphine use.
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Correct Answer is B
Explanation
A. heart rate is not the primary concern when assessing the interaction between NSAIDs and loop diuretics.
B. blood pressure is correct; the combination of an NSAID and a loop diuretic can lead to fluid retention, potentially elevating blood pressure. Monitoring blood pressure is crucial in this context.
C. cognition is not directly impacted by the combination of these medications.
D. assessment for signs of bleeding is important when taking NSAIDs due to their effect on platelet function, but the more immediate concern is the potential fluid retention affecting blood pressure.
Correct Answer is B
Explanation
A. Administer the insulin to the client is incorrect as the nurse should first verify the dosage for safety before administration.
B. Check the dosage with another nurse is correct because double-checking the insulin dosage with another licensed nurse is a critical safety step to prevent medication errors.
C. Check the client's blood sugar again is incorrect; while monitoring blood sugar is important, it is not the immediate next action after preparing the insulin.
D. Ensure a meal tray is available is incorrect; although the client should have a meal ready after insulin administration, the priority action before administering the medication is to confirm the dosage.